“Repeated Hierarchies”: Uneven Participation in Research of Ethical Spaces in Hospitals

Country Context (Including Health Features)

Clinical ethical committees help clinicians deal with ethical challenges experienced in clinical practice. In France, today numerous formal and informal hospital-based committees exist with varying composition and methods; however, the “safe space” created by the ethics committee is not always safe for all participants, given the hierarchical nature of clinical work (Guerrier, 2006). Ethical committees continue to struggle with this hierarchy.

Description of the Research Situation in Which the Ethical Issue Arose

The research team (four women researchers from anthropology, philosophy, and sociology) led a focus group discussion with professionals involved in ethical reflection in hospitals. The goal of the research was to understand (a) the timing, places, and practices where an ethical reflection develops in the hospital; (b) the role of the various actors involved; (c) whether the work of the committee is led in a patient and/or provider perspective; and (d) to think critically as a group about how to make ethical committees more effective in daily practice.

The discussion was focused on two principal questions:

Two focus groups of 1.30 hr responded to the two questions moderated by a facilitator. There were 10 participants in each group, including one facilitator and one note taker. The group in question was a mix of professionals coming from different specialties (geriatrics, philosophy, psychology, palliative care, nursery, urgent care) as well as with different professional roles (doctor, psychologist, nurse trainer, management). They were all female with the exception of one male doctor. All had been involved in ethical committees in hospital settings, except for one student, who was a health care professional midway through her education. The student was included to provide a fresh perspective from someone not fully integrated in the daily work of clinical service. Participants were grouped via tables in a square formation, which meant that everyone could look at and speak to the group. Participants introduced themselves in a round-robin fashion via an anecdote. As Fern (2001) highlights, this differentiation stage allowed members to pick up on verbal and visual cues and to differentiate other group members in terms of status and occupation.

As we used the focus group methodology to see how questions were debated by the participants, the researcher did not directly “intervene” in the debate, except to ask follow-up questions. An important part of our thematic and conversational analysis postdiscussion was to consider the time each person put into the debate to understand at what moment they intervened and why. In the group under discussion, those in hierarchical positions initiated the discussion and largely led the debate. The student participated actively at the beginning but midway through the discussion became silent.

Case Vignette

A female doctor initiated the discussion by introducing an ethical problem experienced in her service. The student expressed her interest by asking her several follow-up questions. Midway through, a nurse started to discuss hierarchical relationships between professionals, saying that it inhibits discussion. She said this hierarchical situation needs to be addressed during the training period, before professionals go to the ward. The nurse trainer agreed with this, saying that frequently students come back from internships unhappy with the limited place for discussion on the ward and that their role as interns did not help.

In response, the student described her own experience. She said that in her service,

When there are complicated situations, they will never ask me what I think. At school they don’t teach us how to discuss an ethical problem with professionals. As a student, I have more the impression to be an observer than an “actor” because they start from the principle that we are there to learn the techniques and to apply the theory.

She gave an example in which her opinion was silenced.

I had a situation which marked me, it was a young homeless patient . . . she gave birth while I was on my internship, and we kept this woman for 15 days because unfortunately she had antecedents of violence . . . we let the patient nurse her child, we let her create a strong relationship, and we let her hope for 15 days that she would be placed with her child. Except at the end, we learned that the courts had decided that the child would be placed in foster care and the mother in the streets. . . I wanted to say what I thought, to say what I saw during these 15 days. . . how she took very good care of her. . . to give my point of view. But they didn’t give me the right to speak at all. They don’t listen to us, we are just observers, and they don’t give us the place to speak. . . .I am the student, I know, but from my point of view, ethically speaking, I would not have let the relationship be created, and I wouldn’t have let this woman be put outside in -10 weather.

One of the respondents, a female psychologist in the same sector, responded by telling her she did not adequately understand the procedure.

In our hospital we do a lot of evaluations, and before proceeding, we call the judge (responsible for the case), and there is a whole multidisciplinary evaluation process with different professionals. . . that allows us to do the most complete possible evaluation at that time . . .after all, it’s the ethics of care. . . what we put into place for the just needs of the mother and the child. . . it doesn’t mean the best, but the least worse possible solution, both for the baby and the mother.

Seeking to soothe the tension, a male doctor then intervened,

We are used to speech which is codified, hierarchical. . . there is the space for the doctor, who has a certain knowledge, and who speaks easily. There is the speech of the nurse, who has a place too. . . but to redistribute these communication cards (learned hierarchical roles) means freeing yourself from this preprogramming, to give the speech to the student for example . . .

Despite this intervention to encourage the student’s viewpoint, she did not participate in the rest of the discussion. The student came to see the facilitator postdiscussion to voice her disappointment at being placed in the same hierarchical situation as in her daily work.

Ethical Issues Arising

This situation suggests that the habitual hierarchical processes of communication among professionals were replayed in the focus group discussion. This was in line with our overall research results, which showed that relationship difficulties between committee members, the effects of hierarchy, and the lack of training in learning how to speak with other professionals block ethical reflection in these spaces.

We chose the focus group methodology to provide “a step away” from the hospital. We believed that holding the discussion in a different environment than from the clinical setting might provide a safer space for discussion. A potential strength in focus group methodology is this possibility to allow a safe space to break the silence about difficult issues, in particular when those issues are shared by others (Hollander, 2004). In addition, it was expressed by several participants during the debate that everyone, as a moral subject, has the same legitimacy to participate.

Conversational analysis of the first part of the discussion showed the student was active. The continuation of the topic into the theme of hierarchy in hospital settings and the difficulties of giving students a place gave an entry point for the student to divulge her own experience. However, the uneven hierarchical structure she experienced in the hospital was repeated during the focus group and she was silenced.

This issue was raised during the presentation of the results. The professional concerned acknowledged the tension felt during the discussion; however, she said that her response to the student was a clarification and that it was always difficult to explain procedures to students. The student did not attend the presentation, so she could not respond.

Conclusion

The status of the different participants did not give adequate space for full participation. Therefore, our methodological goal of providing a “fresh” perspective in the form of the student and a “safe space” to discuss difficult issues at least partly failed. Although this shows the constraints of a collegial reflection, it also suggests that our methodology was inadequate to provide this safe space. It also raises questions for us on how to “fairly” report on this issue as one of the persons involved did not attend the results presentation. Finally, it poses questions for the use of ethics in ethical committees in the first place. If participants are unable to take an egalitarian position even in a focus group in which there is no hierarchy or subordination, how can this function in an ethical committee in a real-world situation?